American College of Physicians Virginia Chapter 2013 Annual Meeting and Clinical Update March 1–2, 2013

Primary Care Follow-Up After Bariatric Surgery

Puneet Puri, M.B.B.S., M.D. Assistant Professor of Medicine Division of Gastroenterology, Hepatology and Nutrition Virginia Commonwealth University, Richmond VA

I have no disclosures related to current presentation Objectives

• Growing burden • Different weight loss surgeries • Nutritional and metabolic consequences • Long term complications • Special populations

Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 (*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

1990 1999

2008

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BRFSS: Behavioral Risk Factor Surveillance System

Relation between BMI and Mortality

Lew EA. Ann Intern Med 1985;103:1024

Dealing with Obesity Epidemic

Samuel I, et al Am J Surg 2006;192:657-62 Types of Bariatric Surgery

Restrictive Restrictive Malabsorptive Malabsorptive Restrictive

Vert Band Gastroplasty Bilio-pancreatic Diversion

Over 90% in US Roux-N-Y Adjustible Gastric Band Gastric Bypass Bilio-pancreatic Diversion with Duodenal Switch Sleeve Gastrectomy Parameter RYGBP BPD-DS VBG LAGB

Weight Loss % EBW 65-70 ~70 50-60 50 % BMI 35 ~35 25-30 25

SI except fibrosis, SI NAFLD SI SI may get worse

SI or R SI or R I or R Diabetes SI or R 65-95% 65-95% 40-65%

Operative Mortality 0.5-1% 1% 0.1% 0.1% Morbidity 5% 5% 5% 5% Complication Stomach dilation, Malabsorption Food/pill Gastric prolapse, ventral hernia Increased AST/ALT, impaction stomal obstruction, resolve after 6 mths Outlet obstruction pouch dilation

Type Restrictive/ Malabsorptive / Restrictive Restrictive Malabsorptive Restrictive

Use in the United 9% 87% 2% 1.4% States Gastric Bypass Surgery The Concept

Gastrojejunostomy

Jejuno-jejunal anastomosis

Proximal RNYGB Roux-en-Y gastric bypass (RYGB)

Ghrelin

GLP-1

PYY

Insulinn

Meirelles K. et al. Mechanisms of Glucose Homeostasis after Roux-en-Y Gastric Bypass Surgery in the obese, insulin-resistant Zucher Rat. Ann Surg 2009 February;249(2):277-285. Case 1

• A 38-yo Caucasian female • Eight month history of ascites • Gastric bypass in 1999 at outside facility • Complaints: – Leg swelling – Increased forgetfulness – Unsteady on feet – Recurrent falls recently – Weak and tired Case 1

• On exam: – 98 lb, 5’3” – Poor dentition & oral hygiene – Muscle wasting – Spider angioma – Ecchymosis – Ascites and edema – Asterixis + • Labs: – Hb 9.7, Plt 106, INR 1.4, Cr 1.0 – AST 46, ALT 33, TBil 1.5, Alb 2.4 – Ascitic fluid alb <1.0, protein 1.9 • Cirrhosis, MELD 12, Child C • Admitted 1 month later with sepsis, had complicated hospital course and after 5 weeks family decided for comfort care Case 1

• 243 lb, lost 103 lb in first year after gastric bypass • Since surgery, had seen PCP at scheduled appointments but no follow up with surgeons • Current BMI 16.3 kg/m2 • Drinks 3-4 cans of beer/day, low vitamin B12 • Poor diet and nutrient supplements • Decompensated Alcoholic cirrhosis • Severe protein calorie malnutrition and cachexia • Vitamin B12 deficiency Take Home Message - Case 1

• Patient compliance for successful outcome – Follow up visits with the surgeon and physicians – Diet and nutrition – Alcohol abstinence • Always know the surgical details/anatomy • Significant excess weight loss? • Physician awareness Case 2

• A 33-yo WF, referred for nutritional management • Gastric bypass in 2006 • C/o nausea, vomiting, abdominal pain, bloating • Leg swelling and abdominal distension • Unable to eat well due to above complaints • Alcohol abuse until 10 months ago • Pallor, abd distended, tender, BS+, edema, asterixis + • Hb 9.6, Plt 122, AST/ALT 126/59, TBil 1.8, AlkP 187, Albumin 2.8, INR 1.4, Cr 1.1 • US abd: small nodular liver, perihepatic fluid, reversal of portal flow with portal vein 15 mm, spleen 13.8 cm Case 2

Small bowel obstruction at the distal small bowel anastomosis: dilated Roux jejunal limb and excluded limb.

Venting gastrostomy tube by IR Liquid diet, tolerated well initially, then became non-compliant

High surgical risk for bowel surgery, liver transplant evaluation initiated to address both liver and bowel issues Initiated on TPN Developed sepsis and did not survive The ABC System of Classification of Small Bowel Obstruction

A Alimentary limb

B biliopancreatic limb

C Common channel

Tucker ON, et al Obes Surg 2007;17:1549–1554 Alcohol Misuse After Bariatric Surgery: Epiphenomenon or “Oprah” Phenomenon?

• Lack of robust data • Alcohol pharmacokinetics study in women with gastric bypass ≥3 years • Compared to age and BMI matched controls, blood alcohol levels – Peaked more quickly – Remained higher • About 90% gastric bypass patients more sensitive to alcohol after surgery

Klockhoff H et al. Br J Clin Pharm 2002; 54 , pp. 587–591 Buffington C et al. Surg Obes Rel Dis 2006;2: 313. Case 3

• 25-yo AAF, had distal gastric bypass 6 months ago • Lost 164 lbs (459 lb to 285 lb) • Admitted with nausea, vomiting, poor oral intake and abdominal pain ~5-6 weeks • Obese, lethargic, apathetic, weakness of extremities 4-/5 • BUN 5, Cr 0.6, Lactate 4.5, Albumin 2.8, Pre-albumin 9, AST/ALT 35/39 Thiamine Deficiency

• Thaimine levels: Low • Thiamine replacement: Gradually improved, lactic acidosis resolved • Thiamine deficiency can cause – Peripheral neurologic – Cerebral – Cardiologic – Gastrointestinal manifestations • Thiamine is absorbed in the small intestine, mostly in the jejunum and ileum. • Even VBG procedures have been associated with thiamine deficiency, probably due to reduced intake, not malabsorption Clinical Presentations of Thiamine Deficiency

Beriberi Subtype Symptoms and Findings

Neuropsychiatric Hallucinations/aggressive behavior Confusion/nystagmus/ataxia/ophthalmoplegia

Wet beriberi Tachycardia/respiratory distress/leg edema Right ventricular dilation/lactic acidosis

Dry beriberi Numbness/muscle weakness and pain of lower to upper extremities/convulsions/Exaggerated tendon reflexes

Gastrointestinal Nausea/emesis and megajejunum Constipation and megacolon

Bariatric beriberi Symptoms corrected by antibiotics, not by oral thiamine Thiamine Deficiency

• Wernicke encephalopathy is caused by severe thiamine deficiency • Classical clinical triad – Ocular changes (nystagmus, ocular nerve palsies), – Ataxia – Aapathetic mental confusion • As early as 2 weeks and as long as 13 years after surgery • Fatalities have been reported • Early recognition and immediate parenteral treatment • Prevention: Multivitamin supplement is adequate • Deficiency: parenteral thiamine 50 to 200 mg per day until symptoms clear, then 10 to 100 mg by mouth daily Famous Words of a Bariatric Surgeon…

In more than 2,000 RYGB procedures, we never saw any evidence of protein-calorie malnutrition, unless the patient had a mechanical problem with excessive vomiting or had undergone a distal gastric bypass

Harvey Sugerman, Former Vice Chair Department of Surgery, VCU Medical Center Letter J Am Coll Surg Nov 2005 Protein Calorie Malnutrition in Gastric Bypass Patients • A real risk • Some patients suffer troublesome vomiting after surgery, until their GI tract adjusts to the changes, and cannot eat adequate amounts even with 6 meals a day • Many patients require protein supplementation during the early phases of rapid weight loss, to prevent excessive loss of muscle mass

• Patient compliance and dedicated team can prevent this Medication Management

• Prevention of gallstone formation • Diabetes • Hypertension • Dyslipidemia • Monitor closely for diuretics • No NSAIDs Luminal Complications of Gastric Bypass • Anastomotic – Leak – Stricture/stenosis – Ulcer • Obstruction – Internal herniation – Adhesions • Dumping syndrome Anastomotic Ulcer Anastomotic Ulcer

• In up to 16% of patients. Possible causes include: – Altered blood supply to the anastomosis – Anastomotic tension – Gastric acid – Helicobacter pylori – Smoking – Use of Non-steroidal anti-inflammatory drugs

• Treatment: – Use of Proton pump inhibitors – Use of a cytoprotectant and acid buffering agent – Temporary restriction of the consumption of solid foods Anastomotic Stricture

• If the inflammation and healing process outpaces the stretching process, scarring may result in stricture formation

• Treatment: EGD and dilation Internal Herniation

Mesenteric Swirl Sign and Mushroom-shaped mesenteric root. Enhanced transverse CT scan through mesenteric root shows narrowed mesenteric root with fat and vessels passing between superior mesenteric artery (arrow) and distal mesenteric arterial branch (arrowhead) Nutritional Aspects of Bariatric Surgery

• Diet recommendation at VCU Medical Center: • Day of surgery: – No food or drink • Day 1 after surgery: (Category 1) – 1/4 cup clear liquids or juice per hour (2 small medicine cups). • Day 2 after surgery: (Category 2) – Full liquid diet (to be followed for 2 full weeks after surgery) Category III – Up to 2 weeks post Gastric Bypass • Full liquid diet (sugar free) • Minimum daily protein intake – Women: 50-60 grams – Men: 65-75 grams • No juice • No sweetened beverages

Category IV: 2-4 weeks post Gastric Bypass • Pureed diet (consistency of applesauce) • Minimum daily protein intake – Women: 50-60 grams – Men: 65-75 grams • No juice • No sweetened beverages

Category V: After 4 weeks of Gastric Bypass

• Regular foods with emphasis on avoiding more difficult to tolerate foods – Meat, Chicken – Bread, Pasta, Rice – Pork, Firm fish • Minimum daily protein intake – Women: 50-60 grams, Men: 65-75 grams • No juice • No sweetened beverages • Avoid sugar, junk, high calorie processed foods • LAGB drink liquids 1 hour before meals • GBP drink liquids 30 minutes before or 1 hour after meals Nutrient Deficiency After Bariatric Surgery

Prevalence (or Complications or Laboratory test * or other Deficiency risk) consequences investigations AGB: + Microcytosis, anaemia, ↓% transferrin saturation (iron) GBP: ++ fatigue, brittle nails CBC (haemoglobin),↓ferritin < Iron SG: + 20mg/L (transferrin soluble receptor) AGB: – or ± Osteomalacia, 1,25(OH)2D, ↑PTH, ↑alkaline Calcium, vitamin GBP: ++ osteoporosis, fractures phosphatase, ↓calcaemia: rare, D SG: - (?) DEXA (↓bone density)

AGB: – Oedema ↓Albumin, ↓prealbumin, DEXA GBP: ± (↓fat-free mass) Proteins SG: – (?)

AGB: + Hair loss (?zinc), ↓Zinc RBC, ↓selenium Zinc, selenium GBP: ++ selenium: no symptoms SG: (?) Nutrient Deficiency After Bariatric Surgery

Complications or Laboratory test * or Deficiency Prevalence (or risk) consequences other investigations AGB: + Macrocytosis, anaemia, ↓Vitamin B12, ↑MMA GBP: ++ neuropathy (optional), Vitamin B12 SG: + (?) ↑homocysteine (optional) AGB: ± Macrocytosis, anaemia, ↓Folate, ↓RBC folate, Vitamin B9 (folate) GBP: ± pregnant women: fetal ↑homocysteine SG: ± neural-tube defects (optional) AGB: ± Neuropathy, Gayet– ↓Thiamine GBP: ± Wernicke Vitamin B1 (thiamine) SG: ± (?) encephalopathy

AGB: – Vitamin A: night Vitamin A, vitamin E, GBP: – or ± blindness, vitamin E: vitamin K1 + INR Other vitamins (A, E, K) SG: – ↑oxidative stress, vitamin K: bleeding disorder 1 month 3 months 6 months 12 months 18 months 24 months Annually

CBC, BMP, AGB AGB AGB AGB AGB AGB AGB Hepatic GBP GBP GBP GBP GBP GBP GBP (optional) SG SG SG SG SG SG SG Iron (% AGB AGB AGB AGB AGB AGB transferrin GBP GBP GBP GBP GBP GBP saturation), SG SG SG SG SG SG ferritin Vitamin B12 (± AGB AGB AGB AGB MMA) GBP GBP GBP GBP SG a SG a SG a RBC, folate AGB AGB a AGB a AGB a AGB a GBP GBP GBP GBP GBP GBP SG a SG a SG a SG a Calcaemia + GBP GBP GBP GBP AGB AGB 25OH D GBP a GBP a SG a SG a Intact PTH GBP GBP GBP b GBP GBP

DEXA, bone GBP AGB Every 2–5 density years GBP SG Albumin AGB AGB AGB (prealbumin) GBP GBP GBP SG SG SG Vitamins and Minerals

VITAMIN FIRST MONTH Multi-vitamin 2 chewable children’s vitamin (does not have to be ‘sugar free’) Iron Iron 65mg twice a day (for menstruating women only). (after the first 2

weeks) You may have to ask the pharmacist for this.

Vitamin B12 Vitamin B12 500mcg tablet per day or one injection (1000 mcg) per month (prescription required) or B12 (1000mcg) sublingual (under tongue) ** Please note the different doses, depending on the type of B12**

• Daily vitamin supplementation Vitamins and Minerals

VITAMIN AFTER 1 MONTH

Multi-vitamin 2 chewable children’s (does not have to be ‘sugar free’ or one adult multivitamin (non-chewable) per day. Calcium Citrate plus Calcium CITRATE plus D, 4 caplets per day- 2 in the am and 2 in the pm. D (Citrical plus D or generic is acceptable) Calcium Citrate is required because it is the only calcium that is properly absorbed after gastric bypass. Ask your pharmacist if you need assistance.

Iron Iron 65mg twice a day (for menstruating women only). You may have to ask the pharmacist for this strength

Vitamin B12 Vitamin B12 500mcg tablet per day or one injection (1000 mcg) per month (prescription required) or B12 (1000mcg) sublingual (under tongue) ** Please note the different doses, depending on the type of B12** DO’s

• DO spread the vitamins and minerals throughout the day • DO consider B12 injections or sublingual (under the tongue) B12 if you do not like to take pills. The sublingual dissolves under the tongue and does not need to be swallowed. You can purchase it at GNC or other vitamin stores. • DO use calcium citrate for calcium supplementation, as it is better absorbed by the body. DO NOT’s

• To avoid nausea, DO NOT take vitamins and minerals on an empty stomach, especially iron. If the iron causes nausea or stomach upset, you can try a less nauseating form of iron called Slow Fe. • DO NOT take calcium and iron at the same time; take at least four hours apart. If you take them together, you will not absorb either of them and are likely to become constipated. • DO NOT take vitamins and minerals with tea, coffee, or cola. The caffeine will prevent them from being absorbed. • DO NOT take Caltrate or calcium carbonate. It will not be absorbed properly. You MUST take Calcium CITRATE plus D (4 pills per day) Five Keys to Success

• No sugar • No junk food • Exercise • Dietary compliance – Full liquid (0-2 weeks ) – Pureed diet (2-4 weeks) • Attitude, attitude, attitude!! Vitamin and Mineral Supplements after Malabsorptive Bariatric Surgery 1. MULTIVITAMIN with MINERALS: 1 chewable tablet, daily to twice a day 2. CALCIUM SUPPLEMENTS: chewable tablets, 1.2 g elemental calcium, daily Specific deficiencies 3. THIAMINE: 100 mg tablet, twice daily or THIAMINE: 100–250 mg intramuscular, monthly 4. NIACIN: 500 mg orally, 3 times daily 5. FOLIC ACID: 1–5 mg orally, daily 6. VITAMIN B12: 1000 mg, intramuscular, monthly or SUBLINGUAL VITAMIN B12: 500 mg tablet once daily 7. VITAMIN A: 10,000 IU orally, daily 8. VITAMIN D (ergocalciferol): 50,000 IU with a meal once weekly (up to 12 weeks) followed by VITAMIN D3 (cholecalciferol): 1000 IU with a meal twice daily 9. VITAMIN E: 800–1200 IU orally, daily 10. VITAMIN K: 5–20 mg orally, daily 11. IRON: iron/vitamin C complex, 1 tablet daily before a meal, iron elixir (through a straw), or parenteral iron 12. ZINC SULFATE: 220 mg capsule, daily to every other day 13. COPPER GLUCONATE: 2 mg capsule, daily to every other day Special Situations

• Pregnancy consideration • Adolescents • Eating disorder • Binge Eating Disorder (BED) • Depression • Risk of suicide • Addictive behavior

Summary

• Early diagnosis and treatment of small bowel obstruction (SBO) after gastric bypass (RYGB) is crucial to avoid the development of catastrophic complications • A very common cause of SBO after RYGB is internal herniation • Protein calorie malnutrition, vitamin and mineral deficiencies are common if not addressed appropriately • Even modest amounts of alcohol can be deleterious in gastric bypass patients • Pay attention to special situations